These ACET members rotated off the council during 1995; however,
they
made substantive contributions to this report.

The following CDC staff members prepared this report:

Susan M. Graham, M.P.H.
Phyllis E. Cruise

Division of Tuberculosis Elimination
National Center for Prevention Services

in collaboration with the

Advisory Council for the Elimination of Tuberculosis

Summary

The recommendations contained in this report update and expand
previously published recommendations for preventing and controlling
tuberculosis (TB) in correctional facilities (MMWR 1989;38:313 20,
325).
The Advisory Council for the Elimination of Tuberculosis (ACET) has
prepared this report to assist officials of federal, state, and
local
correctional facilities in controlling TB among inmates and
employees of
both short- and long-term correctional facilities (e.g., prisons,
jails,
and juvenile detention centers). Additional information about TB is
available in the American Thoracic Society/CDC statements referred
to in
this report.

The transmission of Mycobacterium tuberculosis in correctional
facilities presents a public health problem for
correctional-facility
employees and for inmates and the communities into which they are
released.
ACET recognizes the urgent need to improve TB prevention and
control
practices in many correctional facilities. All correctional
facilities,
even those in which few TB cases are expected to occur, should
designate a
person or group of persons who will be responsible for the
facility's TB
infection-control program and the following three essential TB
control
activities: a) screening -- identifying persons who are infected
with M.
tuberculosis or who have active TB disease; b) containment --
preventing
transmission of M. tuberculosis and adequately treating persons who
have
latent TB infection or active TB disease; and c) assessment --
monitoring
and evaluating the screening and containment activities.
Correctional-
facility officials should form close working relationships with
their state
and local health departments, which can assist correctional
facilities in
formulating, implementing, and evaluating these activities.

INTRODUCTION

Tuberculosis (TB) is a problem in correctional facilities in
the United
States, and effective TB prevention and control in such facilities
is
necessary to reduce TB rates and, eventually, to eliminate TB in
the United
States (1). This report provides an overview of this problem and
general
guidelines for preventing and controlling TB in both short- and
long-term
correctional facilities. * In addition, this report describes the
three
essential activities necessary for a successful TB prevention and
control
program (i.e., TB screening, containment, and assessment) and the
roles of
the correctional facility and the public health department in
achieving the
goals of such programs.

During the past decade, the number of reported TB cases has
increased
substantially in correctional facilities in some geographic areas
of the
United States. For example, among inmates of the New York state
correctional system, the incidence of TB disease increased from
15.4 cases
per 100,000 inmates during 1976 1978 to 105.5 cases per 100,000
inmates
during 1986 (2). By 1993, this incidence was 139.3 cases per
100,000
inmates (New York State Department of Health, unpublished data). In
many
areas, rates of TB cases for prison populations were substantially
higher
than rates for the total population. During 1993, the rate of TB
cases for
the New York state correctional system (139.3 cases per 100,000
inmates)
was more than six times the rate for the total population of New
York (21.7
cases per 100,000 persons) (New York State Department of Health,
unpublished data). Similarly, the incidence of TB disease among
inmates in
New Jersey correctional facilities during 1994 was 91.2 cases per
100,000
inmates, compared with 11.0 cases per 100,000 persons in the state
(3). In
one California state prison, the incidence of active TB disease
during 1991
was 184 cases per 100,000 inmates -- 10 times greater than the
statewide
incidence rate. Transmission of Mycobacterium tuberculosis also was
documented in this California prison (4).

In 1993, as part of expanded national TB case reporting, state
health
departments began to report to CDC whether newly diagnosed TB cases
occurred among persons who were incarcerated at the time of
diagnosis.
Forty-eight reporting areas (i.e., 47 states and New York City)
provided
this information for greater than or equal to 75% of the cases that
occurred in their areas. In these areas, 3.8% of TB patients for
whom
correctional-facility status was reported resided in a correctional
facility at the time of diagnosis (5). During 1994, 4.6% of TB
patients in
51 reporting areas (i.e., 48 states, New York City, the District of
Columbia, and Puerto Rico) were reported as residents of a
correctional
facility at the time of diagnosis (6); in contrast, 0.6% of the
total U.S.
population were confined in prisons and jails during 1994 (U.S.
Department
of Justice, unpublished data). Thus, a disproportionately high
percentage
of diagnosed TB cases in the United States occur among persons
residing in
correctional facilities. Furthermore, previous studies have
documented a
high prevalence of TB infection among inmates, ranging from 14% to
25%
(7 10). Other studies have indicated a correlation between rates of
positive tuberculin skin-test results and length of incarceration,
suggesting that transmission may have occurred within correctional
facilities (11,12).

Populations Affected by TB in Correctional Facilities

An increasing number of persons either work in or are confined
in U.S.
correctional facilities. In 1980, one of every 453 U.S. residents
was
incarcerated; by the end of 1993, that ratio had grown to one in
every 189
residents (13). From 1980 through 1994, the number of prisoners in
federal
and state correctional facilities more than tripled, from 329,821
in 1980
to 1,053,738 in 1994 (13); by mid-year 1995, this number had
increased to
1,104,074 (U.S. Department of Justice, unpublished data). At
mid-year 1994,
the most recent period for which jail data were available, 490,442
adults
were being held in local jails (14). Furthermore, recidivism is a
problem
for the inmate population; in the 1991 Survey of State Prison
Inmates, 61%
reported a history of previous incarceration (15).

The transmission of M. tuberculosis in correctional facilities
presents
a health problem for both inmates and the communities into which
they are
released. In 1991, U.S. jails released 9,929,347 persons, and state
or
federal jurisdictions released 436,991 sentenced prisoners (16).
Inmates
infected with M. tuberculosis who develop active TB disease after
their
release might infect other persons (17), including young children,
who are
especially vulnerable to development of active TB disease if
infected (18).
In a 1991 survey of >20,000 state and federal inmates, 56% of men
and 67%
of women reported having had at least one child; 6% of almost
39,000 female
inmates were pregnant when they entered prison (15). In addition,
correctional-facility employees are at risk for occupational
exposure to
TB, and, if they develop infectious disease, they might infect
their
families and other contacts.

In several recent TB outbreaks in correctional facilities,
failure to
detect active TB disease in inmates resulted in transmission of M.
tuberculosis to other inmates, correctional-facility employees, and
persons
in the community (CDC, unpublished data). Moreover, outbreaks in
New York
and California involving the transmission of multidrug-resistant
strains of
M. tuberculosis (MDR-TB) to both inmates and employees of
correctional
facilities have been reported; during the outbreak in New York, M.
tuberculosis also was transmitted to health-care workers and
patients in a
nearby hospital (19,20).

Factors Contributing to the Prevalence of TB in Correctional
Facilities

A primary reason for the high risk for M. tuberculosis
infection and
active TB disease in correctional facilities is the
disproportionate number
of inmates who have risk factors for exposure to the organism or,
if
infected, for development of active disease. These risk factors
include
infection with human immunodeficiency virus (HIV), substance abuse,
and
being a member of a lower socioeconomic population that has poor
access to
health care. The strongest known risk factor for the development of
active
TB disease among adults who have latent TB infection is coinfection
with
HIV (21,22). Persons who are coinfected with HIV and M.
tuberculosis have
an estimated 8% 10% risk each year for developing active TB
disease,
whereas persons who are infected with only M. tuberculosis have a
10% risk
for developing active TB disease during their lifetimes. Moreover,
in
HIV-infected persons who become infected with M. tuberculosis, the
progression of latent TB infection to active TB disease is often
rapid
(23).

The prevalence of HIV infection and acquired immunodeficiency
syndrome
(AIDS) among inmates has increased substantially during the past
decade,
and the annual incidence of AIDS among prisoners is markedly higher
than
the incidence among the total U.S. population. In the New York
state prison
system, AIDS cases increased steadily from three cases in 1981, a
rate of
43 cases per 100,000 inmates, to 228 cases in 1987, a rate of 574
cases per
100,000 inmates (24). Based on data from the U.S. Department of
Justice for
1993, 0.4% of the total prison population and almost 0.5% of local
jail
inmates were confirmed as having AIDS; from 1991 through 1993,
confirmed
AIDS cases in state and federal prisons more than doubled, from
1,682 to
3,765 cases (25). During 1991 1992, CDC conducted a nationwide HIV
seroprevalence survey that included >70,000 blood samples from
persons
entering adult correctional facilities. Among the inmates in these
facilities, the median HIV seroprevalence was 2.9% (range: zero to
14.9%);
in comparison, during this time period, the overall HIV
seroprevalence
among civilian applicants for military service, a low-risk
population, was
0.06% (26).

HIV infection in inmates has been associated with previous
injection of
illegal drugs, a risk factor more prevalent among inmates than
among the
total population (25); in a 1991 survey of >20,000 state and
federal
prisoners in 45 states, 25% of the inmates reported a history of
injecting-drug use (15). Persons who inject illegal drugs may be at
increased risk for TB even if these persons are not infected with
HIV,
although the reasons for this increased risk are unclear (27). The
use of
crack cocaine also has been associated with transmission of both
HIV and M.
tuberculosis (28,29); 19.8% of state and federal prisoners during
1991
reported a history of crack cocaine use (15). However, even in the
absence
of HIV infection and the use of such drugs, inmates are at
increased risk
for TB because a disproportionately high number are from lower
socioeconomic groups that have poor access to health care and a
high
prevalence of TB infection (30).

Residents of correctional facilities also are at increased risk
for TB
because many of these facilities have overcrowded environments
conducive to
the transmission of M. tuberculosis (12,31). In the 1994 Annual
Survey of
Jails, the jails surveyed were operating at 97% of their rated
capacities
(14). During 1994, according to U.S. Department of Justice reports,
state
prison facilities were operating at 17% 29% above design capacity,
and
federal facilities at 25% above capacity (32). During 1992, 118
(23%) of
503 jurisdictions ** in which the jail populations were large
(i.e., having
an average daily inmate population of greater than or equal to 100
persons)
had been ordered by a court to limit the number of incarcerated
persons or
improve the conditions of confinement because of crowded living
units (32).
Poor ventilation, which is a problem in many correctional
facilities, also
can promote transmission of M. tuberculosis to inmates,
correctional-
facility employees, and visitors (12,31).

TB Prevention and Control in Correctional Facilities

Although the high risk for transmission of M. tuberculosis
demonstrates
the need for effective TB control in correctional facilities, a
1992 93
survey of 82 correctional systems in the United States indicated
that
policies for TB prevention and control in some correctional
facilities did
not meet CDC's recommended standards (33). Many correctional
facilities had
comprehensive written protocols for TB control, but the extent to
which
these protocols were being practiced was not measured (33). The
need for
improved health care in correctional facilities has been advocated
by a
position statement from the American College of Physicians, the
National
Commission on Correctional Health Care, and the American
Correctional
Health Services Association (34) and by others (35). Furthermore,
several
of the nation's courts have determined that inadequate TB control
efforts
constitute deliberate indifference to the medical needs of inmates
and that
inmates have a constitutional right to adequate TB control in
correctional
facilities (33).

The Advisory Council for the Elimination of Tuberculosis (ACET)
recognizes the urgent need to improve TB prevention and control
practices
in all correctional facilities and has prepared this report to
assist
federal, state, and local correctional officials in achieving this
objective. This effort also will require that health departments --
which
have ultimate responsibility for TB prevention and control -- and
legislators devise and implement innovative strategies in their
jurisdictions. The implementation of these recommendations may
require that
stronger legislation and regulations be enacted and adequate
financial
resources be allocated. These improvements in TB prevention and
control
practices are essential for the following reasons:

TB is spread through the air. One highly infectious person can
infect
others who share the same air space.

Prompt initiation of an adequate regimen of directly observed
therapy
(DOT) helps ensure adherence to treatment because either a
medical
worker, a specially trained correctional officer, or a health-
department employee observes the patient swallowing each dose
of
medication. This method of treatment can diminish
infectiousness,
reduce the risk for relapse, and help prevent the development
of
drug-resistant strains of M. tuberculosis.

Inmates who are coinfected with HIV and M. tuberculosis are at
high
risk for developing active TB disease in comparison with
inmates who
are only infected with M. tuberculosis.

A completed regimen of preventive therapy can prevent the
development
of active TB disease in persons who are infected with M.
tuberculosis.

Correctional-facility officials have an opportunity to treat
inmates
who have active TB disease or latent TB infection before such
inmates
are released into the community.

GENERAL GUIDELINES

TB control is an essential element in health care in
correctional
facilities. All correctional facilities, including those in which
few TB
cases are expected to occur, should designate a person or group of
persons
who have experience in infection control, occupational health, and
engineering to be responsible for the TB infection-control program
in the
facility. These persons should have the authority to develop,
implement,
enforce, and evaluate TB infection-control policies. If supervisory
responsibility is assigned to a committee, one person should be
designated
as the contact person to whom questions and problems can be
addressed. In
multifacility systems, one person should be designated to oversee
TB
infection-control activities throughout the system. TB
infection-control
officials and all clinicians who treat inmates or employees of
correctional
facilities should be familiar with this report, other American
Thoracic
Society (ATS)/CDC guidelines concerning TB (1,27,36), and the
National
Commission on Correctional Health Care standards for correctional
facilities (37,38). Medical facilities within correctional
facilities
should conduct a thorough risk assessment and follow the
recommendations in
the "Guidelines for Preventing the Transmission of Mycobacterium
tuberculosis in Health-Care Facilities, 1994" (39).

Correctional-facility officials should form close working
relationships
with state and local health departments. Health departments can
assist
correctional facilities in formulating, implementing, and
evaluating the
following essential TB infection-control activities:

Screening (i.e., the measures used to identify persons who
have
active TB dis-ease or latent TB infection):

All correctional-facility employees and inmates who
have
suspected or confirmed TB disease should be identified
promptly, and the case(s) or suspected case(s) should
be
reported to the health department.

Employees and long-term inmates infected with M.
tuberculosis
(i.e., those who have positive skin-test results)
should be
identified and evaluated for preventive therapy.

Containment (i.e., the measures used to prevent
transmission of M.
tuberculosis):

Persons suspected of having infectious TB disease
should be
placed immediately in an appropriate TB isolation room.
A
thorough contact investigation should be implemented
promptly.

Persons who have suspected or confirmed TB disease
should
promptly begin an adequate treatment regimen.
Appropriate
diagnostic, treatment, and laboratory services should
be
available. All therapy for TB disease should be
directly
observed.

Persons infected with M. tuberculosis, especially those
in
high-risk groups, should have a thorough medical
evaluation and
preventive therapy when appropriate. Preventive therapy
should
be directly observed.

Assessment (i.e., the monitoring and evaluation of
screening and
containment activities). Assessment procedures include the
collection and analysis of data to monitor whether the
following
activities are being implemented successfully:

cases of active TB disease are detected;

persons who have latent TB infection are identified and
evaluated;

cases of TB disease are promptly reported, counted, and
recorded;

persons who begin therapy for active TB disease or
latent TB
infection complete a recommended course of therapy; and

referrals to other correctional facilities or to health
departments are made and confirmed in a timely manner.

SCREENING

Screening Methods

The following methods are usually used to identify M.
tuberculosis
infection or active TB disease. Additional information concerning
these
methods is provided in the ATS/CDC document "Diagnostic Standards
and
Classification of Tuberculosis" (36).

Symptom Screening

Screening for symptoms of TB disease is the first step of
intervention
in locations where the prevalence of TB disease is high. Persons
who have
symptoms of pulmonary TB (e.g., a productive, prolonged cough {a
cough
lasting for greater than or equal to 3 weeks}; chest pain; and
hemoptysis
{coughing up blood}) may be infectious. The index of suspicion
should be
high when pulmonary symptoms are accompanied by general, systemic
symptoms
of TB (e.g., fever, chills, night sweats, easy fatigability, loss
of
appetite, and weight loss). Inmates should be interviewed
systematically to
determine whether they have experienced symptoms in recent weeks.
Inmates
who have symptoms suggestive of TB disease should immediately
receive a
thorough medical evaluation, including a tuberculin skin test, a
chest
radiograph, and, if indicated, sputum examinations.
Chest-radiograph
interpretations and sputum-smear results should be available within
24
hours; skin-test results should be read 48 72 hours after
administration of
purified protein derivative (PPD) by the Mantoux method.

During their initial medical evaluations, inmates should be
asked if
they have had active TB disease or if they have been treated for
latent TB
infection or active TB disease; this information should be recorded
in each
inmate's respective medical records. Any inmate who has a history
of
inadequate treatment for TB disease should undergo a thorough
medical
evaluation. If an inmate has a positive skin-test result and a
diagnosis of
active TB disease has been excluded, the inmate should be
considered for
preventive therapy.

Chest-Radiograph Screening

A posterior-anterior view of the chest is the standard
radiograph
initially needed to detect and describe chest abnormalities. Other
views
(e.g., lateral or apical lordotic views) or additional studies
(e.g.,
computed tomographic {CT} scans) may be necessary for further
evaluation.
When chest-radiograph films are taken of women who may be pregnant,
lead
shielding should be used to protect the pelvic and abdominal area.
Chest-
radiograph interpretations for asymptomatic persons should be
available
within 72 hours; whenever possible, radiography should be performed
on-site
to avoid delays in diagnosis. Sputum-smear and culture examinations
should
be conducted for inmates whose chest radiographs are suggestive of
active
TB disease, regardless of their skin-test results.

Mantoux Tuberculin Skin-Test Screening

The preferred method of screening for TB infection is the
Mantoux
tuberculin skin test using 0.1 mL of 5 tuberculin units (TU) of
PPD.
Multiple-puncture tests should not be used to determine if a person
is
infected. Persons who have a documented history of a positive
skin-test
result, a documented history of TB disease, or a reported history
of a
severe necrotic reaction to tuberculin should be exempt from
routine
tuberculin skin-test screening. Neither pregnancy, lactation, nor
previous
vaccination with Bacillus of Calmette and Guerin (BCG) vaccine are
contraindications for tuberculin skin testing. The Mantoux skin
test is not
a recommended method of screening for active TB disease; an average
of
10% 25% of patients with active TB disease have a negative reaction
to the
tuberculin skin test (40 42).

The reaction to the Mantoux skin test should be interpreted by
an
experienced worker 48 72 hours after the injection by measuring the
area of
induration (i.e., the palpable swelling) at the injection site. The
diameter of the indurated area should be measured across the width
of the
forearm. Erythema (i.e., the redness of the skin) should not be
measured.
All reactions, even those classified as negative, should be
recorded in
millimeters of induration.

Generally, a tuberculin skin-test reaction of greater than or
equal to
10 mm induration is considered a positive result in inmates and
correctional-facility employees. However, an induration of greater
than or
equal to 5 mm is considered a positive result in persons in the
following
groups:

close contacts of a person who has infectious TB (see Contact
Investigation);

persons who are at risk for HIV infection, including
injecting-drug
users whose HIV status is unknown.

Persons who have a positive skin-test result and no symptoms
suggestive of
TB should be screened with a chest radiograph within 72 hours after
the
skin test is interpreted. Persons who have symptoms suggestive of
TB
disease should be evaluated immediately (see Symptom Screening).

Vaccination with BCG, a TB vaccine used in many countries, can
cause a
reaction to the tuberculin skin test. No reliable method can
distinguish
tuberculin reactions caused by BCG from those caused by infection
with M.
tuberculosis. However, a diagnosis of M. tuberculosis infection and
the use
of preventive therapy should be considered for any BCG-vaccinated
person
who has a tuberculin skin-test reaction of greater than or equal to
10 mm
of induration, especially if any of the following circumstances are
present: a) the vaccinated person is a contact of another person
who has
infectious TB, particularly if the infectious person has
transmitted M.
tuberculosis to other persons; b) the vaccinated person was born or
has
resided in a country in which the prevalence of TB is high; or c)
the
vaccinated person is exposed continually to populations in which
the
prevalence of TB is high (e.g., some health-care workers, employees
and
volunteers at homeless shelters, and workers at drug-treatment
centers)
(43). A diagnosis of active TB disease should be considered for
BCG-
vaccinated persons -- regardless of their tuberculin skin-test
results or
HIV serostatus -- if they have symptoms suggestive of TB,
especially if
they have been exposed recently to infectious TB.

HIV-infected inmates who are at high risk for infection with M.
tuberculosis and who do not react to tuberculin may be evaluated
for
skin-test anergy. Anergy testing is accomplished by using the
Mantoux
technique to administer at least two antigens other than tuberculin
(e.g.,
tetanus toxoid, mumps, or Candida) (44). However, the scientific
basis for
anergy testing is not well established, and the skin-test antigens
currently used for anergy testing have not been standardized.
Therefore,
all HIV-infected persons, regardless of whether they are anergic,
should be
screened with a chest radiograph and further diagnostic evaluation
if
indicated. Medical and nonmedical personnel should safeguard the
confidentiality of sensitive information while screening persons
for
infection with M. tuberculosis or active TB disease.

Two-Step Tuberculin Skin-Test Screening

Some persons who are skin tested many years after infection
with M.
tuberculosis have a negative reaction to an initial tuberculin skin
test,
followed by a positive reaction to a subsequent skin test; this
phenomenon
is referred to as a boosted reaction. Boosted reactions to
tuberculin skin
tests are common in older adults and in persons who have been
vaccinated
with BCG. To reduce the likelihood of misinterpreting a boosted
reaction as
a new infection, two-step testing is used for baseline testing of
persons
who periodically will receive tuberculin skin tests. If the result
of the
first test is positive, the person is considered infected with M.
tuberculosis; if negative, a second test should be administered 1 3
weeks
later. To eliminate one appointment, some correctional facilities
wait
until 1 week after the first test both to interpret the reaction to
the
first test and to administer the second test to tuberculin-negative
persons. The reaction to the second test should be interpreted 48
72 hours
after the injection.

A positive reaction to the second test probably represents a
boosted
reaction and is not considered a skin-test conversion. Persons who
have a
negative reaction to the second test should be classified as
uninfected. In
persons who have a negative skin-test result, a positive reaction
to any
subsequent test is considered a skin-test conversion and is likely
to
represent new infection with M. tuberculosis.

Initial Screening

The following procedures should be used for the initial
screening of
inmates, depending on their length of stay in the facility and the
type of
facility, and for all correctional-facility employees, regardless
of the
type of facility.

Inmates in Long-Term Correctional Facilities

Symptom screening should be done as soon as possible for all
new
inmates. Any inmate who has symptoms suggestive of TB should be
placed
immediately in a TB isolation room and evaluated promptly for TB
disease.
In addition, tuberculin skin-test screening of all inmates who do
not have
a documented history of a positive skin-test result should be
mandatory in
long-term correctional facilities. Decisions concerning the use of
two-step
skin testing for inmates entering the facility should be based on
the
frequency of boosting in the facility; in some facilities, two-step
testing
may provide a more reliable baseline. Persons who have a positive
skin-test
result should be screened with a chest radiograph and should be
given a
thorough medical evaluation; if active TB disease is excluded as a
diagnosis, preventive therapy should be considered for these
persons.
Regardless of their tuberculin skin-test status, inmates known to
have HIV
infection, as well as inmates who are at risk for HIV infection but
whose
HIV status is unknown, should have a chest radiograph taken as part
of the
initial screening (Figure_1) (1).

Inmates in Short-Term Correctional Facilities that Provide Service
to
Populations at High Risk for TB

As in long-term facilities, symptom screening should be done as
soon as
possible for all new inmates in short-term facilities. Any inmate
who has
symptoms suggestive of TB should be placed immediately in a TB
isolation
room and promptly evaluated for TB disease. Tuberculin skin-test
screening
usually is not feasible for short-term inmates. However, long-term
inmates
who reside in short-term facilities and who do not have a
documented
history of a positive skin-test result should be tuberculin tested
within
14 days of entry. Persons who have a positive skin-test result
should have
a chest radiograph taken and should be given a thorough medical
evaluation;
if TB disease is excluded as a diagnosis, the inmate should be
considered
for preventive therapy. Regardless of their skin-test results,
inmates
known to have HIV infection, as well as inmates who are at risk for
HIV
infection but whose HIV status is unknown, should have a chest
radiograph
taken as part of the initial screening.

In some large jails, TB control officials should consider using
on-site
chest radiography to screen all inmates, both short-term and
long-term, for
TB disease. Such screening is particularly important for jails in
which a)
the prevalence of TB disease is high, b) the inmate population
changes
rapidly, and c) the prevalence of HIV infection and illicit-drug
injection
is high. Jail officials should consult the local TB control officer
for
assistance in assessing the need for, and cost-effectiveness of,
such
screening. In jails in which chest-radiograph screening is
routinely
conducted, long-term inmates also should be tuberculin skin tested
(Figure_2).

Inmates in Short-Term Facilities that Provide Service to
Populations
at Low Risk for TB

Symptom screening is recommended for all inmates at time of
entry into
the facility. Any inmate who has symptoms suggestive of TB should
be placed
immediately in a TB isolation room and evaluated promptly for TB
disease.
Correctional facilities without an on-site medical facility should
have a
written plan to refer patients who have suspected or confirmed TB
to a
collaborating facility that is equipped to evaluate and manage TB
patients
(Figure_3).

When short-term facilities do not institute an extensive TB
screening
protocol, the decision should be supported by a thorough assessment
of the
risk for M. tuberculosis transmission in the facility. For example,
screening for infection may not be indicated in facilities in which
the
risk for exposure to and transmission of M. tuberculosis is
minimal; such
facilities a) do not contain inmates who have infectious TB, b) are
located
in communities in which no TB cases were reported during the
preceding
year, and c) do not contain inmates who resided in areas in which
TB cases
were reported during the preceding year. In contrast, more
extensive TB
screening may be necessary if cases of drug-resistant TB have been
reported
in the facility or its community or if the prevalence of HIV
infection
among inmates or employees at the facility is high.

Employees in All Correctional Facilities

A medical history should be obtained from and recorded for all
new
employees at the time of hiring, and they should receive a physical
examination. In addition, tuberculin skin-test screening should be
mandatory for all employees who do not have a documented history of
a
positive skin-test result. To improve the accuracy of the baseline
result,
two-step Mantoux skin testing should be used for the initial
screening of
employees who have not been tested in the preceding 12 months.
Persons who
have a positive skin-test result should have a chest radiograph
taken and
evaluated and should be given a thorough medical evaluation; if TB
disease
is excluded as a diagnosis, such persons should be considered for
preventive therapy. All employees should be informed that they
should seek
appropriate follow-up and screening for TB if they are
immunosuppressed for
any reason (e.g., HIV-infected persons, regardless of their
skin-test
results, should have a chest radiograph taken and evaluated). Any
employee
who has symptoms suggestive of TB should not return to the
workplace until
a physician has excluded a diagnosis of infectious TB disease.

Facilities in which the risk for infection with M. tuberculosis
is
minimal may not need to maintain an ongoing tuberculin skin-testing
program. However, administering baseline skin tests to employees
would
enable medical staff to distinguish between a skin-test conversion
and a
positive skin-test result caused by a previous exposure to M.
tuberculosis
(Figure_4).

Follow-Up Screening

Long-term inmates and all employees who have a negative
skin-test
result should have an annual PPD skin test. Persons who have a
history of a
positive skin-test result and who have not completed a course of
preventive
therapy should be screened for symptoms of TB disease. However,
annual
chest radiographs are unnecessary for the follow-up evaluation of
infected
persons. Tuberculin skin-test results should be recorded in the
person's
medical record and in a retrievable aggregate database of all
tuberculin
skin-test results. Personal identifying information should be
confidential.

The database should be analyzed periodically to estimate the
risk for
acquiring new infection in the correctional facility; however, this
analysis should be completed by using only the skin-test results of
a)
employees and b) inmates who have remained in the facility
continually
during the interval between skin tests. The tuberculin skin-test
conversion
rate equals the number of employees whose skin-test results have
converted
from negative to positive during a specific time interval (i.e.,
the
numerator) divided by the total number of previously PPD-negative
employees
who were tested during the same specific time interval (i.e., the
denominator). Conversion rates also can be calculated for
previously
PPD-negative inmates who were tested during the same specific time
interval
if these inmates remained in the facility continually since their
last skin
test. In some facilities, data analysis of skin-test results for
specific
areas or groups within the facility may be appropriate.

Additional investigation, and possibly more frequent testing,
are
needed when a tuberculin skin-test conversion rate is substantially
higher
than previous rates. A cluster (i.e., when two or more tuberculin
skin-test
conversions occur in the correctional facility and the
epidemiologic
evidence indicates transmission has occurred within the facility)
or other
evidence of person-to-person transmission also warrants additional
epidemiologic investigation *** or a revision of the facility's TB
prevention and control protocol.

Diagnosis

All persons who have a positive skin-test result or symptoms
suggestive
of TB should receive a thorough medical evaluation, and a chest
radiograph
should be taken and evaluated. A negative skin-test result does not
exclude
the diagnosis of active TB disease, especially for patients who
have severe
TB disease or HIV infection. Abnormalities on a chest radiograph
might
suggest, but do not confirm, a diagnosis of active TB disease.
However,
chest radiographs may be used to exclude the possibility of
pulmonary TB in
a person who has a positive skin-test result but no symptoms of
disease.

At least three sputum specimens obtained from a person
suspected of
having pulmonary or laryngeal TB should be examined using an
acid-fast
bacilli (AFB) smear and culture. A series of three specimens should
be
collected during the early morning on different days. Sputum should
be
submitted for AFB smear and culture examinations from persons who
are
diagnosed initially with other respiratory diseases (e.g.,
pneumonia) but
whose symptoms do not improve within 14 days after initiation of
treatment.
Aerosol induction can be used to obtain specimens if sputum cannot
be
produced spontaneously. Precautionary infection-control measures
should be
used during sputum collection, sputum induction, bronchoscopy, and
other
diagnostic procedures.

Detection of AFB in stained sputum smears examined
microscopically may
provide the first bacteriologic indication of TB disease; however,
smear
examination enables only the presumptive diagnosis of TB because
the AFB on
a smear may be mycobacteria other than M. tuberculosis.
Furthermore, the
sputum smears obtained from TB patients might be negative for AFB.
Smear
examination is a rapid and relatively easy procedure to perform;
results
should be available within 24 hours after the laboratory receives
the
specimen. The results of the smear examination can be used to help
determine the infectiousness of the patient; patients whose
sputum-smear
results are positive are considered infectious because they can
expel many
tubercle bacilli into the air when they cough or sneeze.

A positive culture for M. tuberculosis confirms a diagnosis of
TB
disease. In the absence of a positive culture, TB also may be
diagnosed on
the basis of clinical signs and symptoms. When liquid culture media
and
rapid identification methods are used, culture results are usually
available within 2 3 weeks after specimen collection. For all
patients, the
initial M. tuberculosis isolate should be tested for drug
susceptibility.

TB can be difficult to diagnose in HIV-infected persons or
other
severely immunosuppressed persons (36). A high frequency of
extrapulmonary
involvement, usually with concomitant pulmonary TB, is a striking
clinical
feature of TB in these patients, especially in patients who have
severe
HIV-induced immunosuppression (45). The chest radiographs of
severely
immunosuppressed persons who have pulmonary TB might not have a
classical
appearance; for example, infiltrates without cavities in any lung
zone or
mediastinal or hilar lymphadenopathy might be present. In rare
situations,
the chest radiograph of a severely immunosuppressed person who has
pulmonary TB disease may appear normal (46).

Case Reporting

All states require designated health-care professionals to
report cases
of TB to the local or state health department; this reporting is
mandatory
for all correctional facilities, whether private, federal, state,
or local.
Correctional-facility medical staff should report any suspected or
confirmed TB cases among inmates or employees to the appropriate
health
agency in accordance with state and local laws and regulations.
Cases must
be reported to access health department resources for case
management and
for contact investigation in both the facility and the community.
For each
suspected case of TB, the diagnosis or the exclusion of a diagnosis
of TB
should be entered immediately into a) the person's medical record,
b) the
retrievable aggregate TB control database at the facility, and c)
the
database at a centralized office if the system has multiple
facilities. In
addition, drug-susceptibility results should be sent to the state
or local
health department for use in monitoring the rates of drug
resistance in the
health department's jurisdiction.

Contact Investigation

A prompt and thorough contact investigation is essential for
the
control of TB. Persons who have confirmed pulmonary or laryngeal TB
should
be considered infectious if they meet two criteria. First, the
person
either a) is coughing, b) is undergoing cough-inducing or aerosol-
generating procedures, or c) has had a sputum smear that was
positive for
AFB. Second, the person either a) is not receiving therapy, b) has
just
started therapy, or c) is having a poor clinical or bacteriologic
response
to therapy.

When a person who has suspected or confirmed TB might be
infectious,
close contacts of that person should be skin tested unless they
have a
documented history of a positive tuberculin skin-test result (1).
Close
contacts include persons who live with, work with, or otherwise are
frequently in close physical proximity to a person who has
infectious TB.
These contacts are at highest risk for acquiring infection.
Depending on
the ventilation in a correctional facility and the infectiousness
of the
index patient, close contacts in correctional facilities could
include all
cell mates of the infectious person, all inmates and employees on a
tier or
unit, and all inmates and employees in a building.

All persons should be considered potential contacts if they
could have
been exposed to the patient when the patient was likely to have
been
infectious. Contacts also might include frequent visitors, inmates
or
employees who are no longer at the facility, and family or
community
members who were in close contact with the patient before the
incarceration. Contacts who are children or who have HIV infection
should
be evaluated as soon as possible after the exposure.

Because the public health department is responsible for
identifying and
testing contacts outside the correctional facility, the health
department
should be consulted to help determine who should be screened for
possible
TB infection. To help identify contacts within the facility,
correctional
facilities should maintain a tracking system that documents inmate
transfers, releases, and moves within a facility or system; this
information should be available, when necessary, to other
correctional
facilities and to the health department.

If the skin testing of close contacts indicates that the rate
of
positive skin-test results in this group exceeds the expected rate,
the
investigation should be extended to include persons who have had
less
frequent contact with the patient. Health departments should help
determine
when a contact investigation should be extended to include such
persons.

Contacts should be screened with a chest radiograph if they
have a
skin-test result of greater than or equal to 5 mm induration or
symptoms
suggestive of active TB disease; those persons who do not have
evidence of
active TB disease should be evaluated for preventive therapy.
Contacts
whose initial skin-test result is <5 mm of induration should be screened with a chest radiograph and should be considered for preventive therapy in the following situations:

the contact is a child or adolescent;

the contact is immunosuppressed, especially because of HIV
infection;

the contact was exposed to a person who was highly infectious
(i.e.,
who had not been treated for TB at the time of this exposure
and who
either a} had pulmonary or laryngeal TB and a cough or was
undergoing
cough-inducing procedures, b} had a positive AFB sputum smear,
or c}
had cavitation on chest radiograph);

the environment in which the contact was exposed to M.
tuberculosis was
conducive to transmission of the organism;

M. tuberculosis was transmitted to other persons who had a
similar
degree of exposure to the infectious person.

Contacts who have a negative reaction to an initial skin test
should be

retested 10 12 weeks after their last known exposure to M.
tuberculosis.
Preventive therapy can be discontinued if the result of the second
skin
test is negative and the contact has had no further exposure to
infectious
TB. Contacts who are infected with HIV should be considered for
preventive
therapy regardless of their skin-test results (1). All involved
personnel
should ensure the confidentiality of sensitive information during
the
contact investigation.

If the sputum-smear result of a patient who has clinically
active TB
disease is negative, that patient probably is not infectious.
However, if
this patient could have been infected recently with M.
tuberculosis, close
contacts of that person should be evaluated to determine the
probable
source case and to identify other newly infected inmates or
employees.

CONTAINMENT

Isolation

Persons who have suspected or confirmed pulmonary or laryngeal
TB
disease should be placed immediately in a TB isolation room that
meets
recommended standards (39). Moving a patient to another facility or
hospital that has an available TB isolation room may be necessary.
TB
isolation procedures can be discontinued if a diagnosis of TB is
excluded.
If a diagnosis of TB cannot be excluded, the patient should remain
in
isolation until the patient is determined to be noninfectious.
Current
guidelines recommend daily monitoring of TB isolation rooms in use
so that
negative pressure is maintained and air is exhausted properly (39).
No
special precautions are needed for handling the patient's dishes,
books,
laundry, bedding, or other personal items.

The length of time required for a TB patient to become
noninfectious
after initiating TB therapy varies considerably. Isolation should
be
discontinued only when the patient is receiving effective therapy,
is
improving clinically, and has had three consecutive negative AFB
smears
from specimens collected on different days. In patients who have
drug-
resistant TB, the response to treatment should be closely
monitored, and TB
isolation should be maintained until noninfectiousness has been
determined.
Prolonged isolation should be considered for patients who have
MDR-TB
because these patients are more likely to experience treatment
failure or
relapse, both of which can prolong infectiousness.

Because crowded living conditions and poor ventilation are
conducive to
the transmission of M. tuberculosis, improvements in housing
conditions can
help prevent outbreaks. Standard engineering controls are based
primarily
on the use of ventilation systems, which might not prevent
transmission of
M. tuberculosis. These ventilation systems may be supplemented with
high-
efficiency particulate air (HEPA) filtration and ultraviolet
germicidal
irradiation (UVGI) in high-risk areas (e.g., temporary holding
areas and
communal areas). HEPA filters can be used in ventilation systems to
remove
droplet nuclei from the air. UVGI lamps can be used in ceiling or
wall
fixtures or within air ducts of ventilation systems to kill or
inactivate
M. tuberculosis contained in droplet nuclei. When HEPA filtration
or UVGI
is used, proper installation and maintenance are essential to
ensure
effective operation and reduction of potential health hazards
(e.g.,
conjunctivitis caused by UVGI overexposure) (39,47).

If inmates who are suspected of having infectious TB must be
transported outside their TB isolation rooms for medically
essential
procedures that cannot be performed in the isolation rooms, they
should be
required to wear a surgical mask that covers their mouth and nose
during
transport. Medical or security staff who transport infectious TB
patients
in a closed vehicle or who must enter TB isolation rooms should
wear a
personal respirator. A respiratory protection program, including
education
and fit testing (i.e., testing for proper fit of respiratory
equipment),
should be included in the correctional facility's TB
infection-control
program (39).

Treatment

Current ATS/CDC recommendations should be followed for the
treatment
and management of persons who have suspected or confirmed TB
disease (27).
For most patients, the preferred initial treatment regimen includes
four
drugs: isoniazid, rifampin, pyrazinamide, and either ethambutol or
streptomycin. Three drugs (isoniazid, rifampin, and pyrazinamide)
may be
adequate for the initial regimen if the possibility of drug
resistance is
unlikely. Drug resistance does not usually occur when the primary
isoniazid-resistance rate in the community is <4% and the patient a) has not been treated previously for TB, b) was not born in or has not resided in a country in which the prevalence of drug-resistant TB is high, and c) has had no known exposure to a patient with drug-resistant TB. Because pyrazinamide and streptomycin should not be used to treat pregnant women, pregnancy must be excluded in women of child-bearing ages before treatment for TB disease is initiated.

For persons who have positive sputum smears or cultures at the
initiation of therapy, response to treatment should be monitored by
smear
and culture examination at least monthly until the results are
negative.
Failure to respond to treatment usually is caused by patient
nonadherence
to therapy, but it also can be caused by a drug-resistant strain of
M.
tuberculosis. Drug-susceptibility testing should be performed on
all
initial M. tuberculosis isolates, regardless of sputum-smear
results. If
cultures continue to be positive after 2 months of recommended
therapy, or
if the patient's condition does not improve or worsens,
drug-susceptibility
tests should be performed again, and adherence to the prescribed
regimen
should be reassessed.

All patients should be monitored by trained personnel for signs
and
symptoms of adverse reactions during therapy. A thorough medical
evaluation
is necessary if the patient develops drug intolerance or has signs
or
symptoms of an adverse reaction. In some situations, adjusting the
regimen
to enable completion of therapy may be necessary. Expert medical
consultation should be sought for monitoring and treating patients
who have
complex psychosocial problems or associated medical conditions
(e.g., AIDS,
diabetes, pregnancy, or extrapulmonary or drug-resistant TB). HIV
counseling and testing should be offered to all inmates who have
active TB
disease. HIV-infected patients who have active TB disease should be
monitored closely for treatment failure, relapse, and adverse
reactions to
medications (27).

All inmates being treated for active TB disease should be on
DOT to
ensure adherence to therapy. When DOT is used, TB medication may be
administered either a) twice weekly (with an appropriate change in
dosage)
after an initial period of daily medication or b) three times
weekly from
the beginning of therapy (27).

Inadequate or interrupted treatment for TB can result in
relapse,
continued transmission, and the development of drug-resistant
disease.
Therefore, after effective therapy has begun, continued treatment
without
interruption is critical until patients complete an entire course
of
therapy. If treatment lapses for any reason, prompt action should
be taken
to ensure that therapy is reinstituted. If an inmate is to be
released or
transferred out of the facility before completing therapy, the
public
health department or receiving correctional facility should be
notified as
far in advance as possible and should be provided with appropriate
medical
records to ensure continued adherence to and timely completion of
therapy.
Innovative efforts should be made to encourage released inmates to
complete
treatment for active TB disease; such efforts can decrease the
number of TB
patients who are lost to follow-up. For example, among persons
released
from Rikers Island Correctional Facility in New York City, an
expanded
outreach program and the use of incentives increased the percentage
of
released inmates who went to follow-up medical appointments from
<20% to 92% (48).

Preventive Therapy

The recommended regimen for preventive therapy in adults is a
single
daily dose of 300 mg of isoniazid for 6 12 months. Regardless of
their
ages, persons in the following high-risk groups should be evaluated
for
preventive therapy if they have a positive skin-test result:

persons known to be infected with HIV who have a skin-test
result of
greater than or equal to 5 mm induration;

persons who are at risk for HIV infection (including
injecting-drug
users whose HIV status is unknown) and who have an induration
of
greater than or equal to 5 mm;

persons who have had close contact with a person who has
infectious TB
and who have an induration of greater than or equal to 5 mm;

persons who have chest-radiograph findings suggestive of
previous TB
but who have received inadequate or no treatment and who have
an
induration of greater than or equal to 5 mm;

injecting-drug users who are known to be HIV negative and who
have an
induration of greater than or equal to 10 mm;

persons who have medical conditions known to increase the risk
for TB
disease and who have an induration of greater than or equal to
10 mm
(see Glossary: Medical conditions known to increase the risk
for TB);
and

persons whose tuberculin skin-test result converted from
negative to
positive within the preceding 2 years and who have a greater
than or
equal to 10 mm increase in the size of induration if <35 years of age or a greater than or equal to 15 mm increase if greater than or equal to 35 years of age.

Persons in these high-priority groups should start a course of

preventive therapy unless treatment is medically contraindicated.
In
addition, in the absence of any risk factors, correctional-facility
employees or inmates <35 years of age should be evaluated for preventive therapy if their reaction to the tuberculin skin test is greater than or equal to 10 mm (27,39) . These persons should start preventive therapy only if they are likely to complete a regimen of at least 6 months of preventive therapy (i.e., the correctional facility has formal agreements with collaborating facilities and the local health department for referral and follow-up upon transfer or release of the inmate).

Regardless of their ages, persons coinfected with HIV and M.
tuberculosis are at high risk for developing active TB disease.
Therefore,
HIV counseling and testing should be offered to all inmates who
have had a
positive skin-test result. In addition, HIV-infected persons, or
persons
who are at risk for HIV infection but whose HIV status is unknown,
should
receive 12 months of preventive therapy if they have a positive
skin-test
result.

Preventive therapy given to inmates always should be directly
observed
by a medical worker or other specially trained person. Because
daily
supervised therapy often is not feasible, twice-weekly supervised
therapy
is suggested as a satisfactory alternative when directly observed
preventive therapy is used. Twice-weekly intermittent preventive
therapy
(using 15 mg/kg of isoniazid per dose, with a maximum dose of 900
mg) is
considered to be safe and effective, although this therapy has not
been
studied in controlled clinical trials (27). Medication should not
be given
to an inmate without direct observation of drug ingestion. Before
release
or transfer of an inmate, provisions should be made for the public
health
department or receiving facility to oversee completion of an
appropriate
course of preventive therapy.

During the entire treatment period, persons receiving
preventive
therapy should be monitored monthly by medical personnel for signs
and
symptoms of adverse reactions. Because isoniazid-associated
hepatitis
occurs more frequently among persons ages greater than or equal to
35
years, transaminase measurements should be obtained for persons in
this age
group at the initiation of preventive therapy and monthly during
the course
of treatment (27). Other factors associated with an increased risk
for
hepatitis include chronic liver disease, daily use of alcohol,
injecting-
drug use, a history of discontinuing isoniazid because of adverse
reactions, or current use of another medication that might cause
interactions. Persons in some demographic groups might have an
increased
risk for severe or fatal cases of isoniazid-associated hepatitis;
case
clusters have been reported among both black and Hispanic women,
particularly among Hispanic women during postpartum periods (49).
Persons
in these high-risk groups may require more careful monitoring
during
preventive therapy; such monitoring might include more frequent
liver
function tests. If any of these test results exceeds three to five
times
the upper limit of the normal range, isoniazid should be
discontinued and a
thorough clinical evaluation should be conducted promptly. Liver
function
tests are not a substitute for monthly clinical evaluations or for
the
prompt assessment of possible adverse reactions that might occur
between
regularly scheduled evaluations (27).

Persons for whom TB preventive therapy is recommended but who
refuse or
are unable to complete a recommended course of therapy should be
counseled
to seek prompt medical attention if they develop signs or symptoms
suggestive of TB. Routine, periodic chest radiographs of persons
who have a
documented history of a positive skin-test result usually are not
useful
for detecting disease in the absence of symptoms. Chest radiographs
should
be taken only if symptoms, especially a persistent cough, develop.

ASSESSMENT

Inmates in large jails and prison systems are transferred
frequently
from one facility to another and from one unit to another within a
facility. Thus, a retrievable aggregate record system is essential
for
tracking all inmates and for assessing the status of persons who
have
active TB disease and latent TB infection in prisons and jails.
This record
system should maintain current information about the location,
screening
results, treatment status, and degree of infectiousness of these
persons.
The record system also should provide the information necessary to
assess
the overall effectiveness of TB control efforts. The following
information
should be reviewed at least annually:

the numbers of correctional-facility employees and inmates
currently
infected with M. tuberculosis;

the number of newly infected persons (i.e., those who have
skin-test
conversions);

the number of persons for whom preventive therapy was
initiated;

the percentage of persons who completed the prescribed
preventive
therapy regimen, excluding those released from or transferred
out of
the facility;

the number of diagnosed TB cases and the case rate;

the percentage of persons in whom active TB disease was
diagnosed who
completed the prescribed treatment regimen, excluding those
released
from or transferred out of the facility;

the number of infectious (i.e., smear-positive) patients; and

the percentage of released or transferred inmates who kept
their
scheduled referral appointment.

In a multifacility correctional system, these data should be
compiled

for each facility, and for all the facilities in the system, and
then
provided to correctional-facility and health-department officials.
In large
correctional facilities, analysis of the data by unit may be
necessary.
ACET has established the following goals: a) at least 95% of
persons who
begin preventive therapy should complete the prescribed regimen
(excluding
inmates released from or transferred out of the facility); b) at
least 95%
of persons in whom active TB disease is diagnosed should complete
the
prescribed treatment regimen (excluding inmates released from or
transferred out of the facility); and c) at least 90% of released
or
transferred inmates should keep their scheduled referral
appointments.

ROLE OF THE CORRECTIONAL FACILITY

The correctional facility should be responsible for in-facility
TB
screening, containment, and assessment unless otherwise mandated by
legal
statute. In all correctional facilities, officials should work
closely with
the state and local health departments in their jurisdictions.
Correctional
facilities, including local jails, should establish formal written
working
agreements with health departments in their areas. These written
agreements
should delineate responsibilities and specify procedures for the
following
activities:

screening and treatment of inmates,

follow-up of symptomatic inmates,

follow-up of inmates who have abnormal chest radiographs,

contact investigations for reported TB cases,

follow-up of inmates released before completing treatment for
TB
disease, and

follow-up of inmates released before completing preventive
therapy.

Correctional facilities also should collaborate with health
department
staff to provide TB education and counseling to inmates and
employees.

ROLE OF THE PUBLIC HEALTH DEPARTMENT

Public health departments should assist correctional facilities
in
developing and updating policies, procedures, and record-keeping
systems
for TB control. The health department also should provide access to
expert
TB medical consultation and ensure that correctional facilities
have access
to adequate laboratory services. A specific health department
contact
person should be designated to provide epidemiologic and management
assistance to correctional facilities. These duties initially may
require
on-site consultation at the correctional facility. Small jails may
need
more direct support from the health department (e.g., to perform
screening
activities or administer DOT).

Health-department personnel should assist in developing
programs to
train correctional-facility personnel for activities such as a)
performing,
interpreting, and recording tuberculin skin tests; b) identifying
signs and
symptoms of TB; c) initiating and observing therapy; d) monitoring
medication side effects; e) collecting diagnostic specimens; f)
educating
inmates; and g) maintaining record systems. Some health departments
and
correctional facilities have encouraged participation in such
programs by
certifying correctional-facility employees who complete the
training
courses. Health department officials also should provide
educational
information concerning TB to senior-level prison and jail
authorities and
to county boards of supervisors and other elected officials.

In addition, health departments should provide consultation for
contact
investigations for each case within correctional facilities and
ensure
appropriate examinations for community contacts of persons
diagnosed with
or suspected of having active TB disease in these facilities.
Health
department staff also should cooperate with correctional-facility
staff in
identifying TB among persons who enter the correctional facility
and in
arranging continued treatment of inmates who are released while
receiving
TB treatment or preventive therapy.

Health departments should maintain TB registries containing
updated
medical information on all current TB patients in their
jurisdictions,
including those in correctional facilities. Cross-matching
information from
the TB registry with the names of inmates admitted into
correctional
facilities can help identify persons who have active TB disease but
who did
not provide this information to correctional-facility personnel;
cross-
matching also can help locate patients lost to follow-up (New York
City
Department of Health, unpublished data). TB case records should be
assessed
quarterly, and necessary revisions in policies or procedures should
be
recommended. The reported information on TB cases among inmates and
correctional-facility staff should be assessed periodically by
health
departments to determine the communitywide impact of M.
tuberculosis
infection and TB disease in correctional facilities.

Because inmates could be coinfected with HIV and M.
tuberculosis,
health department officials should assist correctional facilities
in
developing and implementing HIV-prevention programs that include
strategies
for a) identifying persons who practice high-risk behaviors, b)
reducing
high-risk behaviors among all inmates, and c) counseling
HIV-infected
persons.

CONCLUSION

These recommendations will be revised periodically as
necessary. They
are not intended to discourage new and innovative approaches in
addressing
TB prevention and control in correctional settings, but should be
used to
enhance the quality of medical care for all persons in correctional
facilities.

A glossary is provided that defines these and other terms
contained in
this document.

** A jurisdiction is the territorial range over which a federal,
state, or
local governmental authority extends.

*** For a detailed explanation of how to conduct such an
investigation, see
CDC's "Guidelines for Preventing the Transmission of Mycobacterium
tuberculosis in Health-Care Facilities, 1994" (39).

References

American Thoracic Society/CDC. Control of tuberculosis in the
United
States. Am Rev Respir Dis 1992;146:1623 33.

Weiner J, Anno BJ, American College of Physicians, National
Commission
on Correctional Health Care, American Correctional Health
Services
Association. The crisis in correctional health care: the impact
of the
National Drug Control Strategy on correctional health services.
Ann
Intern Med 1992;117:71 7.

CDC. The role of BCG vaccine in the prevention and control of
tuberculosis in the United States: a joint statement by the
Advisory
Council for the Elimination of Tuberculosis and the Advisory
Committee
on Immunization Practices. MMWR 1996;45(No. RR-4).

Mycobacterium tuberculosis complex, which are sometimes
referred to as
the tubercle bacillus. Persons who have active tuberculosis
(TB)
disease usually manifest symptoms that differ depending on the
site of
disease. The symptoms of pulmonary TB (i.e., the usual form of
TB)
include cough, chest pain, and hemoptysis; general symptoms of
TB
include fever, chills, night sweats, easy fatigability, loss of
appetite, and weight loss.

Close contact: A person who lives with, works with, or otherwise is

frequently in close physical proximity to a person who has
infectious
TB.

Directly observed therapy (DOT): Therapy in which either a
health-care

worker, a specially trained correctional officer, or a health-
department employee observes the inmate swallow each dose of
medication.

High-risk populations: a) Populations in which the prevalence of
infection

with M. tuberculosis is high (e.g., close contacts of a person
who has
infectious TB; persons who were born in or have resided in
countries in
which the prevalence of TB is high; medically underserved,
low-income
populations; residents of long-term care facilities; and
persons who
inject illegal drugs) or b) populations that are at high risk
for
developing active TB disease if they become infected with M.
tuberculosis (e.g., persons infected with HIV, persons recently
infected with M. tuberculosis, persons who have medical
conditions
known to increase the risk for developing active TB disease,
injecting-
drug users, or persons who have a history of inadequately
treated TB).

Infectious: Capable of transmitting M. tuberculosis. Persons who
have

clinically active pulmonary or laryngeal TB disease can expel
droplets
containing M. tuberculosis into the air. Persons are usually
considered
infectious if their sputum smears are positive for acid-fast
bacilli
and they a) are not on therapy, b) have just begun therapy, or
c) are
on inadequate therapy.

Inmate: Any prisoner, detainee, or other resident of a correctional

facility, whether adult or juvenile, sentenced or unsentenced.

Latent TB infection: A condition in which a relatively small number
of

living tubercle bacilli (i.e., M. tuberculosis) are present in
the body
but are not multiplying or causing clinically active disease.
Although
infected persons usually have positive tuberculin skin-test
reactions,
they have no symptoms associated with the infection and are not
infectious. However, infected persons remain at lifelong risk
for
developing active TB disease; preventive therapy can
substantially
reduce this risk.

ventilation characteristics appropriate for isolation, as
described in
the "Guidelines for Preventing the Transmission of
Mycobacterium
tuberculosis in Health-Care Facilities, 1994" (39) . These
rooms should
maintain negative air pressure; thus, doors to isolation rooms
should
be kept closed except when patients or personnel must enter or
exit the
room. TB isolation rooms should have a sufficient number of air
changes
per hour to enable a reduction in the concentration of droplet
nuclei. Figure_1

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